Acute Communicable Disease Control Manual (B-73

)
REVISION—MARCH 6, 2015

MEASLES (Rubeola)
(Red measles, hard measles, 10-day measles, morbilli)
1. Agent: Measles (rubeola) virus.
2. Identification:
a. Symptoms: Acute, highly communicable
febrile illness with cough, high fever,
conjunctivitis, coryza, and Koplik's spots
on buccal mucosa. Erythematous, maculopapular rash first appears on face
(commonly around ears and hairline)
about 2-4 days following onset of
prodrome. Rash usually spreads to other
parts of body and becomes confluent in
about 4-7 days. Complications include
otitis media, pneumonia, dehydration,
convulsions (with or without fever), and
acute encephalitis. Subacute sclerosing
panencephalitis (SSPE) is extremely rare.
b. Differential Diagnosis: Distinguish from
Kawasaki disease, rubella, scarlet fever,
and other childhood exanthems. See
EXANTHEMS—DIFFERENTIAL
DIAGNOSIS (Appendix A).
c. Diagnosis: A presumptive diagnosis is
based on clinical and epidemiological
grounds. The presence of measles IgM
antibody in a person with a febrile rash
illness usually confirms the diagnosis of
measles and is preferred. (IgM antibodies
can also be detected in individuals
recently vaccinated against measles for
up to 6 weeks after vaccination.) A fourfold or greater increase in specific
hemagglutination-inhibition
(HI)
or
complement fixation (CF) IgG antibody
titers between acute and convalescent
specimens also confirms the diagnosis.

6. Transmission: Direct contact with infectious
droplets or less commonly, by airborne
spread. Measles is one of the most readily
transmitted communicable diseases.
7. Communicability: From 4 days before
beginning of rash to 4 days after its
appearance. Patients with SSPE are not
contagious.
8. Specific Treatment: Supportive care; no
antiviral agent available.
9. Immunity: Lifelong. Persons can be
considered immune to measles only if they
have had a documented history of physiciandiagnosed
measles,
have
laboratory
evidence of immunity, or have documented 2
doses of a measles-containing vaccine on or
after the first birthday. Birth before 1957 is
not a reliable indicator of immunity,
particularly in healthcare personnel.
REPORTING PROCEDURES
1. Reportable. Section 2500, California Code
of Regulations. Report by telephone
immediately at time of identification of case
or suspected case by calling 888-397-3993
(for Los Angeles County). Do not wait for
laboratory confirmation before reporting a
suspected measles case to the local
health department.
2. Report Form: MEASLES (RUBEOLA)
CASE REPORT (CDPH-8345).
MEASLES EXPOSURE INTERVIEW FORM
3. Epidemiologic Data:

3. Incubation: About 10 days, varying from 813 days from exposure to onset of fever;
average 14 days until rash appears; rarely as
long as 21 days. Encephalitis can occur 2-6
days after rash.

a. History of immunization. Number of doses
of measles vaccine and dates
administered.

4. Reservoir: Human.

b. History of exposure(s), 8-21 days prior to
rash onset.

5. Source: Respiratory tract secretions and
fomites.

c. Travel history, with dates of exit from and
re-entry into the United States. Include

PART IV: Acute Communicable Diseases
MEASLES — page 1

Susceptible
contacts are those who in addition to being
born in 1957 or after and having contact with
the case during the infectious period. use Measles Exposure Interview
Form. or having been present
in these areas within two hours of a
communicable measles case. airplane. prompt airborne
isolation is required for 4 days after onset of
rash. lack a
written record showing dates of receipt of at
least two doses of measles-containing
vaccine (i.
e. recently vaccinated
persons will have a positive IgM for measles.e..
Refer to “Public Health Nursing Home Visit
REQUIRED Algorithm” (B-73 Part IV Public
Health Nursing Home Visit Protocol). home. For contact
investigation. Prompt reporting of cases provides
opportunity for better outbreak control. can
complicate the diagnosis of measles if
adverse events to the vaccination occur (i. PRIMARY
CONTACTS:
Identify
all
individuals exposed to patient from 4 days
before to 4 days after rash onset.
CASE:
Precautions:
1. neighbors.
2.
Investigation of measles cases will be a
collaborative effort between the Immunization
Program and the public health district wherein
the case resides.
rash.
1. clinic waiting
room. Case finding: Identify rash illnesses
among household members. vaccination at
a time when it will not prevent measles.. should
be scheduled for vaccination after the 21 day
surveillance period has ended.
CONTACTS:
f. isolation should be maintained for the duration of
the illness. and
secondary contacts within 24 hours so effective
prophylactic measures can be taken for contacts.
Immunize susceptible contacts to limit the
spread of disease as follows: for persons ≥ 6
months of age with one or no documented
doses of MMR.e.
The initial interview of the measles case (or
guardian) will be conducted by Immunization
Program staff. and other household
visitors.
e. give MMR if < 72 hours of
exposure (if vaccine not contraindicated).g. given
within 6 days of exposure. MMR or MR) received on or
after the first-birthday.
3. Respiratory precautions during prodrome
and for 4 days after appearance of rash. however.
CONTROL
CARRIERS
OF
CASE. List of primary and secondary group
contacts. IG should be used as postexposure prophylaxis to protect susceptible
PART IV: Acute Communicable Diseases
MEASLES — page 2
. A district public health nurse
home visit will be made on all measles cases. Also. or a written record of
measles seropositivity.)
If MMR vaccine is contraindicated..Acute Communicable Disease Control Manual (B-73)
REVISION—MARCH 6. Disinfect fomites soiled with nose and throat
secretions and urine. fever). it may prevent or
modify disease. primary contacts.
Investigate case. No
harm has been noted if vaccine is given later
in incubation period. or jointly by Immunization
Program staff and the district public health nurse
in the event that the case (or guardian). (Advise women of childbearing age
to avoid becoming pregnant for one month if
MMR or MR vaccine is administered. 2015
travel history with dates of travel to other
counties or states. Immune status of household and other
close contacts.
CONTACTS
&
Public Health Nursing Protocol:
Home visit is required – a face to face interview
is required..
especially
“out-of-country”
visitors. With hospitalized patients.
schoolmates. cannot
be contacted prior to the scheduled home visit. In immunocompromised patients. immune
globulin (IG) given in the first 3 days after
exposure will usually prevent disease. unless they
develop measles in which case they will be
immune.
d. etc. Keep out of school or work and avoid social
contacts. A measles
exposure is defined as sharing the same air
space with a communicable measles case. same classroom.
Unvaccinated persons who cannot be
vaccinated < 72 hours after exposure.
4. etc.

INSTITUTIONS: If exposure occurs in an
institution. >400 mg/kg
<3 weeks before the measles exposure
should be sufficient to prevent infection. For persons
already receiving IGIV therapy. SURVEILLANCE OF CONTACTS: All
contacts. It can. patients on
treatment for ALL within and until at least six
months
after
completion
of
immunosuppressive chemotherapy. the recipient should be considered
infectious from 5 to 21 days after exposure. Contact and arrange
immunization if susceptible. close
contact.
If a primary contact becomes ill with
measles.5 mL/kg of body weight.) for each group to assist in determining
persons exposed. be
used in other susceptible persons with an
intense measles exposure who cannot be
vaccinated with MMR within three days of
exposure such as non-immune health care
workers. Report all institutional exposures
immediately to Immunization Program.Acute Communicable Disease Control Manual (B-73)
REVISION—MARCH 6.
Measles vaccine should not be given for at
least 5 months after the administration of IG.5 mL/kg of body weight
of IG given intramuscularly (IGIM). number of susceptibles
exposed.
In post-exposure prophylaxis. include the secondary contact
information with a telephone report of spread
case(s) to the Immunization Program. clinic manager. irrespective of evidence of measles
immunity.
etc. patients who have
received a bone marrow or stem cell
transplant until at least 12 months after
finishing all immunosuppressive treatment.
Note:
Severely
immunocompromised
patients include patients with severe primary
immunodeficiency. also. It should not be used in an attempt
to control measles outbreaks. Susceptible pregnant women
should receive 400 mg/kg of IG given
intravenously
(IGIV). IG should be
administered to infants less than 12 months
of age as follows: 0. this
information can be used by Immunization
Program to assist in subsequent investigations
and
to
link
future
cases
epidemiologically.
3. maximum
dose of 15mL. IGIM
(0. susceptible primary contact. prolonged. 2015
persons who are at risk for severe
complications if they develop measles
(examples. both primary and secondary. SECONDARY CONTACTS: Defined as
contacts to susceptible household or other
close.
2. all occupants of same quarters.
should be followed for signs and symptoms
of measles for 21 days after exposure. or
longer where the patient has developed
graft-versus-host disease.
Severely
immunocompromised individuals (see note
below). Ask
susceptible individual contacts (primary
contacts who may be incubating measles)
about groups with which they had or may
have contact within 8-21 days after case's
rash onset to identify secondary contacts.
Because post-exposure immunization or
administration of IG is not completely effective. ward. and persons
immunocompromised as a result of a
medical condition or medication regardless of
prior measles vaccination). If
the primary contact develops measles.
PART IV: Acute Communicable Diseases
MEASLES — page 3
. max dose=15 mL
can be given to other persons who do not
have evidence of measles immunity but
priority should be given to persons exposed
in settings with intense.
Carry out investigation and preventive measures
as above. infants less than 12 months of
age. This
will then be forwarded to other health
district(s) for investigation of the spread
case(s). pregnant women. and to help monitor for illness
among group contacts. Do not offer IG
to eligible secondary contacts unless primary
contact has developed signs of disease. should receive 400 mg/kg of IG
given intravenously (IGIV).
or classroom are considered primary contacts. Any
contacts (primary or secondary) that develop
measles should be reported to the
Immunization Program and investigated
using a separate investigation form and
investigation number.
CARRIERS: Not applicable. church secretary. Identify all
secondary contacts during follow-up of
primary contacts.
some experts would include HIV-infected
persons who lack recent confirmation of
immunologic status or measles immunity. Establish a liaison (team
coach. and
patients with a diagnosis of AIDS or HIVinfected persons with CD4 percent <15% (all
ages) or CD4 <200 lymphocytes /mm3 (age
>5 years) and those who have not received
MMR vaccine since receiving effective ART.

especially. Immunization (General): In Los Angeles
County public clinics. Immunization Requirement for School
Attendance:
Measles
immunization
PART IV: Acute Communicable Diseases
MEASLES — page 4
.
2. IG should be used to protect
susceptible individuals for whom vaccine
is not appropriate or is contraindicated
and who are exposed to measles. Approximately
95% or more of susceptible individuals
develop serum antibody after initial dose.
MMR vaccine is recommended for all
measles-susceptible. Data indicate that
vaccination with MMR has not been
associated with severe or unusual
adverse events in such individuals.
or severe reaction to prior MMR. The interval between
doses should be at least one month. Two
doses of live MMR vaccine are recommended for all persons born after
1956.
require documentation that they are
immune to measles or that they have
received two doses of MMR vaccine.
Tuberculosis patients may be immunized
after therapy has begun. the first dose of liveattenuated MMR (measles.
d.
Vaccine should be given 14 days before
or deferred for 3 to 11 months after
immune globulin or blood transfusion
depending on the product received. and
rubella) vaccine is given at 12 months. see “d” below) or
suppressed immune responses from
leukemia. Indications for Immunization: MMR
vaccine is indicated for all individuals
susceptible to measles. or generalized
malignancy. Contraindications to Use of Live
Vaccines: If a woman is pregnant or
intends to become pregnant in the next
one
month. this
increases to more than 99% after second
dose. children. Other
Contraindications
Vaccine:

for
MMR
Anaphylaxis due to gelatin. adolescents. asymptomatic HIVinfected persons and should be
considered for susceptible symptomatic
persons
who
are
not
severely
immunosuppressed.
and adults. irradiation.
e. unless otherwise
contraindicated (see item "b" below). All health care workers. As a general rule.
MMR
vaccine
is
contraindicated. 2015
School
Exclusion
of
Un-Immunized
Contacts: If a case is reported at a school. Education: Public education by health
departments and private physicians
should encourage measles vaccine for all
susceptible infants. unless child is immunized or shows
proof of immunization within 2 days. IG
should not be given with measles
vaccine.
c. alkylating
drugs. or from therapy with
corticosteroids. These children will be excluded until 21
days after last case was at school while
infectious. Children
through 18 years of age who have not
previously received the second dose of MMR
should be immunized.
vaccines should not be given to pregnant
women. the
second dose of MMR is given to children 4-6
years old or at kindergarten entry. A
person whose most recent dose of measles
vaccine was given before the first birthday
should be considered un-immunized and
given another dose of MMR. ideally 2
weeks prior to travel.

PREVENTION-EDUCATION
1. the
Immunization Program will exclude from school
any children on medical or personal beliefs
waiver. Other Considerations: Measles disease
can be severe in HIV-infected persons.
Students entering college or university within
6 months should be immunized with second
dose of MMR (if not previously received).
b.
 Patients with a high fever or severe
illness should be deferred immunization
with MMR until recovery. All
foreign travelers who are not immune to
measles should be vaccinated. lymphoma. mumps.
Contact Immunization Program for
specific intervals. Unvaccinated
Infants 6 months of age and older should
be vaccinated if they are traveling out of
the country. or antimetabolites should not
receive live vaccine of any kind.
a. live
Patients with immune deficiency
diseases (except HIV.Acute Communicable Disease Control Manual (B-73)
REVISION—MARCH 6. neomycin.

redgray rubber stopper or gold plastic stopper). the currently recommended IgM
EIA is often positive at the time the patient
first presents for medical evaluation. Virus Isolation: Within 6 days of rash onset
obtain a throat swab and place in tube of
viral transport medium and collect urine
specimen in sterile container. Presence of IgG in the
acute specimen indicates prior exposure to
measles. are examined for IgG. if not able to send on same day. sterile specimen container for
urine.
Storage: Send to Public Health Laboratory
as soon as possible at 4°C and ship cold with
ice packs.
Material: Whole clotted blood. preferably within 7 days of
onset of rash. in such
instances when measles is suspected.)
Amount: For venous blood. all children attending daycare centers and public/private schools (K12) are required by state law to show proof of
receiving a measles immunization on or after
the first birthday or else have on file a formal
parental waiver before being allowed entry
into school. Serology: Clinical and epidemiological
histories are required to aid the laboratory in
test selections.
Although IgM antibody is generally
detectable from 2-3 days to 2-3 weeks after
rash onset. In California. There are two serologic tests
available. one of which is MMR.
2. either naturally or by immunization.
Note: In instances where serological testing
has already been performed by a private
laboratory. ideally 8-10 ml
in serum separator tube (SST. Sera should be stored for no
longer than 7 days before testing.
serum collected earlier than 3 days after rash
onset can be falsely negative. Avoid repeat freezethaw cycles.
but within 10 days of rash onset. red-gray
rubber stopper or gold plastic stopper). With
some test kits that still might be in use.
urine.
Container: Viral culturette for NP or throat
specimens.5ml capillary tubes for
serum collection can be used for finger-stick
specimens). and transport on dry ice. If after 6 days.
Paired sera. If unable to ship
within
48
hours.
Laboratory Form: Test Requisition and
Report Form H-3021
Examination Requested: Measles culture
and PCR. If possible. a second specimen is
not routinely necessary.
Container: Serum separator tube (SST.
freeze
specimen
immediately at -70°C (except for urine which
should not be frozen).
Material: Nasopharyngeal or throat swab. three 0. Collect second (convalescent)
specimen approximately 14-28 days after
first blood is drawn. Children entering kindergarten
and 7th grade are required to show proof of
having received 2 doses of a measlescontaining vaccine. 2015
requirement for school attendance (from daycare center through college) is an important
and effective means of measles control in the
USA. (With
prior notification and consent of the testing
laboratory. (If the IgM is positive in
the acute specimen. both tests
should be performed on the acute sample. A four-fold or
greater rise in measles IgG titer is indicative
of recent infection.
Laboratory Form: Test Requisition and
Report Form H-3021
Procedure: Collect the acute specimen as
early as possible.Acute Communicable Disease Control Manual (B-73)
REVISION—MARCH 6.
PART IV: Acute Communicable Diseases
MEASLES — page 5
. Viral isolation permits
epidemiological comparison with other
isolates.
o
Storage: Store at 4 C and ship cold with ice
packs as soon as possible.
refrigerate. the
test should be repeated.
DIAGNOSTIC PROCEDURES
1. an acute specimen taken within
7 days after the onset of the rash and a
convalescent specimen taken 14-28 days
later. Immunization Program staff will
request that the original specimen be sent to
the Public Health Laboratory for confirmation. Keep specimens on wet
(water) ice and send to Public Health Lab as
soon as possible. collect only
urine specimen. IgM and IgG.